Elsevier

Comprehensive Psychiatry

Volume 55, Issue 8, November 2014, Pages 1855-1861
Comprehensive Psychiatry

Correlates of psychiatric hospitalization in a clinical sample of Canadian adolescents with bipolar disorder

https://doi.org/10.1016/j.comppsych.2014.08.048Get rights and content

Abstract

Objective

To identify factors associated with psychiatric hospitalization among adolescents with bipolar disorder (BD).

Methods

Participants were 100 adolescents, ages 13–19, who fulfilled DSM-IV criteria for bipolar I disorder [(BD-I), n = 26], bipolar II disorder [(BD-II), n = 40], or operationalized criteria for BD not otherwise specified [(BD-NOS), n = 34], via the Schedule for Affective Disorders and Schizophrenia, Present and Lifetime version (KSADS-PL). Demographic, clinical, and family history variables were measured via clinical interview with the participant and a parent or guardian.

Results

The lifetime prevalence of psychiatric hospitalization was 50%. Significant predictors of psychiatric hospitalization in univariate analyses included older age, BD-I, history of suicide attempt, psychosis, lifetime use of second generation antipsychotics (SGAs), lithium, SSRI antidepressants and any medication. BD-II was negatively associated with psychiatric hospitalization. In multivariable analyses, older age, history of suicide attempt, psychosis and use of SGAs were positively associated with hospitalization, whereas BD-II was negatively associated with hospitalization.

Conclusions

Psychiatric hospitalization in adolescents with BD is highly prevalent and associated with older age and proxies for greater illness severity. Further studies are needed to identify strategies for reducing the need for psychiatric hospitalizations among adolescents with BD.

Introduction

Bipolar disorder (BD) is a recurrent and impairing illness that is associated with substantial burden of mood symptoms and comorbidity among adults and youth [1], [2], [3]. BD often requires high treatment usage [4], and more than 75% of adults with BD report one or more lifetime psychiatric hospitalizations [5]. With widespread decreases in the number of psychiatric beds, psychiatric hospitalization in recent years is often precipitated by acute crises that necessitate hospitalization for the purpose of risk containment. As such, psychiatric hospitalization is often a decision driven by immediate need rather than individual preferences among patients, families, and/or practitioners. Concerns about hospitalization relate to the disruptive and distressing experience psychiatric hospitalization can be for patients with BD and their families, and the substantial costs incurred [6], [7]. The overall treatment costs of patients with BD have been found to exceed those for other behavioral and mood disorders [8], [9], [10], a disparity that is attributable in large part to hospitalizations which account for 20% of these costs [11].

Investigation of clinical characteristics associated with hospitalization can potentially help align outpatient treatment focus toward preventing these outcomes and identify patients at risk for hospitalization. Hospitalizations among adults with BD have been associated with substance use disorders (SUD) [12], [13], [14], [15], rapid cycling [16], [17], psychosis [18], previous hospitalization [19], [20], BD-I subtype [21], female gender [22], [23], various medications [11], [16], [17], [18], [24], [25], [26], [27], [28], minority status [18], polypharmacy [27], and marital separation [13].

While there is a larger literature on this topic among adults with BD, there is a growing body of literature regarding the rates and correlates of psychiatric hospitalization among adolescents with BD. Hospitalization rates for psychiatric disorders in youth, especially BD, have increased markedly in the past 20 years [29], [30], [31], [32], [33]. The annual rate of hospitalization among adolescents with BD in the US was found to be 39.6% in 2003 [8]. Annual rates in children and adolescents increased 434% between 1997 and 2010 [29], which coincided with a large increase in number of BD diagnoses for this age group [30], [31]. Adolescents with BD are hospitalized more often than those with most other psychiatric and behavioral disorders [34], [35], [36], [37], and rates of inpatient service use now exceed even those of adults with BD in some reports [22]. Female gender [38], [39], comorbid health conditions [39] and having a parent with SUD [38] have all been shown to be directly associated with hospitalization in adolescents with BD, while suicidal or self-injurious behavior [35], comorbid physical conditions in general [39] and rapid cycling [38] are associated with use of highly restrictive treatment settings.

The purpose of this report is to expand the literature on mental health service use among adolescents with BD by investigating characteristics associated with psychiatric hospitalization in a treatment-seeking sample from a sub-specialty clinic at a tertiary academic health sciences center in Canada. Most previous studies on the topic of psychiatric hospitalizations among youth with BD are derived from American populations, and differences in the two nations' health care systems [40], [41] suggest the need to examine this topic among Canadian adolescents specifically. In particular, the absence of universal healthcare to date may render barriers that are not present in socialized healthcare [42], which may cause for differences in factors associated with psychiatric hospitalization.

Section snippets

Sample and setting

The present study includes 100 participants, ages 13–19, with BD-I (n = 26), BD-II (n = 40), or BD-not otherwise specified (NOS; n = 34). Participants were seeking outpatient assessment and/or treatment at a sub-specialty clinic in a tertiary academic health sciences center. Written informed consent was provided by parent(s) and adolescent before study commencement. Research ethics board approval was obtained. At least one parent/guardian for each adolescent also participated.

Subject assessment

Diagnoses (current and

Socio-demographic characteristics of adolescents with bipolar disorder who had a psychiatric hospitalization

Socio-demographic characteristics of all participants are portrayed in Table 1. Of the 100 adolescents with BD, 50% had at least one lifetime psychiatric hospitalization. Participants with, versus without, a history of psychiatric hospitalization were significantly older. Gender, race, socioeconomic status and living with both natural parents were not significantly associated with psychiatric hospitalization.

Clinical and familial characteristics of adolescents with bipolar disorder who had a psychiatric hospitalization

A comparison of clinical characteristics distinguishing those who have a lifetime

Discussion

This study found that 50% of the Canadian adolescents with BD in our sample had a history of psychiatric hospitalization. The current study is the only one to our knowledge to examine a wide range of correlates of psychiatric hospitalization in Canadian adolescents with BD. We found older age, BD-I, history of attempted suicide, psychosis, lifetime use of SGAs, lithium, SSRI antidepressants and any medication to be positively associated with psychiatric hospitalization, while BD-II was

Conclusions

Many findings in the current study are congruent with the current literature in the US regarding psychiatric hospitalization in both adolescent and adult BD. The narrowed focus on psychiatric hospitalization is infrequent in the literature, especially in regards to adolescents, and identified several novel correlates that warrant further investigation. Psychiatric hospitalization is often a crisis-oriented intervention that, although often necessary, is also often disruptive to patients and

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